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North Dakota Medicaid expands coverage for autism services

A therapy used widely to treat symptoms of autism will now be accessible through North Dakota Medicaid after an unsuccessful legislative bid to mandate its coverage in the state's insurance markets.

The North Dakota Department of Human Services announced Friday that the state's updated Medicaid plan will provide coverage for applied behavioral analysis, or ABA, a therapy regimen that encourages individuals to develop more social behaviors. That coverage is now available to Medicaid-eligible individuals up to age 21 who meet certain additional criteria, including diagnosis of an autism spectrum disorder and a recommendation for ABA therapy from a primary care provider.

Sandy Smith is the executive director of the North Dakota Autism Center in Fargo, a nonprofit entity that provides ABA services among other therapy programs. Smith, whose son has autism, has previously described ABA as the "standard of care" for those on the autism spectrum. She described the therapy's inclusion under Medicaid as a "game-changer" for families of children with autism.

"This is really, really huge," Smith said.

The North Dakota Department of Health estimates there are about 11,150 people in the state who have been diagnosed with autism. As of the start of 2016, the state Department of Public Instruction had a record of almost 1,175 students with an educational determination of autism.

Private insurers in most states are required by law to provide coverage for sessions with ABA therapists but, with the March defeat of HB 1434 in the state Senate, North Dakota is one of just a handful of states without a mandate. That status means that families seeking ABA sessions often pay for the therapy out of pocket, though North Dakota's leading private insurance companies have promised to begin covering ABA therapy beginning Jan. 1, 2018.

Though the state mandate failed, the inclusion of ABA under Medicaid—a federal-state venture to provide health coverage to people with low incomes—is the result of a directive passed down by the Centers for Medicare and Medicaid Services, also known as CMS. As of 2014, ABA has been considered by Medicaid leaders as a medically necessary therapy within the required benefits of the program's Early and Periodic Screening, Diagnostic and Treatment section.

North Dakota human services has a biennial budget of $18.3 million to provide autism services through the state Medicaid plan. LuWanna Lawrence, the department's public information officer, said in email that figure is divided evenly between state and federal contributions and was calculated to include the addition of ABA services.

The therapy was previously available through the North Dakota Medicaid plan only through a waiver system that provides a limited number of slots for North Dakota children. Currently there are 47 slots.

Maggie Anderson, director of the Medicaid section of North Dakota human services, said the newly added autism services to the state plan are a matter of compliance with CMS instruction.

"Having these in the waiver, where we had a finite number of slots, did not afford children access to service if it were determined they had need for that," Anderson said.

Though there are still far more people with autism than there are waivers in North Dakota, the widening state Medicaid plan is expected to coincide with the opening of 37 new slots that could become available sometime in the next four months. Unlike the program as a whole, which looks to family income as criteria, the waiver takes into account the income of the child who would be receiving services. Anderson said that creates opportunities for care to families not eligible for Medicaid as a whole.

Moving forward, the state is now looking to build its workforce of licensed ABA therapists that are enrolled in the state Medicaid system. Currently, there are none, though there are some trained ABA therapists that have been working outside of Medicaid.

Smith attributes the general lack of focus on ABA in North Dakota to the historic difficulties in billing and payment for the service in the state. Anderson said her department's Autism Spectrum Disorder Task Force is focused on building policy to help attract a wider pool of specialists.

Sen. Joan Heckaman, D-New Rockford, is a member of the task force and said the expanded access to ABA is a "very important, big step" for North Dakota. Still, Heckaman doesn't believe the work of the task force is done.

"It's an issue that needs to be continuously looked at but also continuously worked at because we're not even coming close to providing all the services that are needed across the state," she said. "That's our goal, to get to that point where everyone's covered if they need services."

Andrew Haffner

Andrew Haffner covers higher education and general assignment stories for the Grand Forks Herald. He attended the University of Wisconsin in Madison, where he studied journalism, political science and international studies. He previously worked at the Dickinson Press.

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